Alaa S. Mahmoud

The Effect of Antenatal Steroids on Fetal Lung Maturation between the 34th and 36th Week of Pregnancy

Aim: To evaluate the effect of antenatal treatment with a single dose of betamethasone between the 34th and the 36th week of pregnancy on the maturation of fetal lung. Methods: To study 100 pregnant women in their 34th–36th week of pregnancy who were diagnosed as susceptible to have preterm delivery. Fifty patients did not receive betamethasone (group 1). The other 50 patients were administered 12 mg betamethasone in a single dose (group 2). Patients who delivered at least 24 h after the administration of betamethasone were included in this study. After delivery, the Apgar score and the development of respiratory distress syndrome (RDS) in the neonates were compared. Results: Group 2 babies had better Apgar scores when compared to group 1, and the difference was statistically significant. Sixteen (32%) neonates of group 1 and 7 (14%) neonates of group 2 required resuscitation, and the difference was statistically significant (p = 0.032; OR = 0.34, 95% CI 0.12–0.93). RDS was detected in 8 newborns of group 1 and 2 of group 2. The difference was statistically significant (p = 0.046; OR = 0.21, 95% CI 0.04–1.08). Conclusion: The administration of a single dose of betamethasone to pregnant women in their 34th–36th week of pregnancy who are likely to have preterm delivery reduces RDS development. There is a need for larger studies to confirm these results.

Diagnosis and management of intra-abdominal, mislocated intrauterine devices

PurposeTo evaluate the predisposing factors, diagnosis and surgical treatment options of patients with intra-abdominal, mislocated intrauterine devices (IUDs).MethodsThe diagnosis and management of 18 patients with intra-abdominal, mislocated IUDs were analyzed in this retrospective study.ResultsTrained midwives inserted ten (55%) of the IUDs, while six (33%) were inserted by general practitioners and two (11%) by specialist gynecologists. Ten (55.5%) of the patients were diagnosed by gynecological examination and ultrasonography (USG); abdominal X-ray, in addition, was required in the other eight (44.4%). Eleven patients (61%) were managed by laparoscopy, whereas laparotomy was required in seven (39%). For all patients, laparoscopy was performed initially. No complication was encountered in any of the patients.ConclusionPersons who insert IUDs should receive adequate training before certification, because inadequate pelvic examination before insertion and inexperience of the inserting person might be predisposing factors for uterine perforation. If IUD strings are not visible during gynecologic examination, USG should be tried to locate the IUD and pelvic X-ray used only when USG fails to locate the IUD. Laparoscopy can be the first choice for removal.

Management and outcomes of adnexal torsion: a 5-year experience

PurposeTo discuss the surgical results of patients with diagnosis of adnexal torsion.MethodsOne hundred and fifty patients with diagnosis of adnexal torsion who presented to our clinic between January 2005 and December 2009 were included in this retrospective analysis. Data regarding age, gravidity, parity, size of mass, operation time, and duration of hospitalization were recorded and compared between the patients who had laparoscopy to those who had laparotomy. The pathological results of patients were also recorded.ResultsFifty-eight patients were treated laparoscopically while 92 patients had laparotomy. The most frequent presenting symptom was pelvic pain (96%). Laparoscopy group consisted of young patients with low parity; operation and hospital stay time was shorter in laparoscopy group. Velocity loss in Doppler ultrasonography was noted in 81.3% of the patients. Of the laparotomy group 35 postmenopausal patients had hysterectomy and bilateral salpingo-oopherectomy, and staging surgery was done for 16 of them. The pathological finding was found to be malignant in four and borderline serous tumor in four patients.ConclusionLaparoscopy is preferred for young patients who want to preserve their fertility. Because of high risk of malignancy in postmenopausal ovarian masses presenting with torsion; frozen section should be used. If not possible or not conclusive, staging surgery is more appropriate especially if there is suspicion of malignancy.

Appendiceal Mucocele Mimicking a Cystic Right Adnexal Mass

OBJECTIVE Appendiceal mucocele is formed by cystic dilatation, abnormal mucinous secretion and epithelial proliferation of the appendiceal lumen. Mucocele may be a finding in cases of benign or malignant neoplasms, and can lead to the development of pseudomyxoma peritonei. CASE REPORT A 71-year-old woman presented with a 3-day history of right lower abdominal pain radiating to her right thigh. A simple 5 x 7 cm cyst with smooth borders and a thick capsule was detected in the right adnexal area by transvaginal ultrasonography. Magnetic resonance imaging identified a 4 x 8 cm cystic lesion in the area of the right ovary. The patient was admitted to our clinic with an initial diagnosis of adnexal cyst, later found to be appendiceal mucocele. CONCLUSION The signs and symptoms of appendiceal mucocele are not specific. Because of its anatomic position, it should be considered in the differential diagnosis of adnexal masses.

Effect of pre-amniocentesis counseling on maternal pain and anxiety.

Aim:  The aim of this study was to evaluate the levels of anticipated and perceived pain and anxiety in expectant mothers at the times of pre‐counseling, post‐counseling, and post‐amniocentesis and to investigate the effect of pre‐amniocentesis counseling on the level of pain and anxiety.

Comparison of induction of labor with vaginal misoprostol plus oxytocin versus oxytocin alone in term primigravidae

Objective. To compare the efficacy and complications of intravaginal misoprostol application before starting oxytocin infusion with oxytocin infusion alone for labor induction in term primigravidae pregnancies with low-Bishop score. Methods. This randomized study included 101 primigravidae women with singleton pregnancies >38 weeks and a Bishop score of <6. Group 1 (50 patients) received a 50-μg dose of intravaginal misoprostol, with an oxytocin infusion started 3 h later. Group 2 (51 patients) received only an oxytocin infusion for labor induction. The time from induction to delivery, the route of delivery and complications were analyzed. Results. The mean time from induction to delivery was 10.4 ± 2.1 h in Group 1 and 13.7 ± 3.4 in Group 2 (p < 0.001). The rates of vaginal delivery, Apgar scores at 1st and 5th min, placental abruption, and postpartum hemorrhage were similar between the two groups. Conclusion. Intravaginal application of 50-μg misoprostol before starting oxytocin infusion is a more effective method of labor induction than oxytocin infusion alone in term primigravidae pregnant women with low-Bishop scores.

The efficacy of multiple-dose methotrexate treatment for unruptured tubal ectopic pregnancy and conversion rate to surgery: a study on 294 cases

In this prospective study 294 patients diagnosed with ectopic pregnancy (EP) were treated with multiple-dose methotrexate (MTX) to determine the conversion rate to surgery. We concluded that multiple-dose MTX treatment had a low success rate, and the success rate was not related to initial b-hCG value; it was more related to the size of gestational mass before treatment.

Removal of intra-abdominal mislocated intrauterine devices by laparoscopy

This retrospective study was carried out on 15 patients who underwent laparoscopy for the removal of a mislocated IUD from 2003 to 2009. The mean duration of usage of an IUD was 16.1 months. The IUD was found in the Pouch of Douglas in six patients; in the posterior wall of the uterus in three patients; in the adnexa in three patients; in the omentum in two patients and it was embedded in the rectal serosa in one patient. The types of the IUDs were TCu-380A (n = 13) and Mirena® (n = 2). The mean laparoscopic operation time was 25 min. No major complications occurred. A second ancillary port was required in three patients. All patients were discharged within 24 h. Laparoscopic removal of the intra-abdominal IUD must be the first choice of therapy. If possible, a single ancillary port should be preferred for the removal of mislocated IUDs. We advise that surgical removal and surgical risk should be discussed with the patients, even if asymptomatic.

Induction of labor with vaginal misoprostol plus oxytocin versus oxytocin alone

To compare the effect of an oxytocin infusion alone or preceded by an intravaginal application of misoprostol for labor induction in women with term pregnancies and a low Bishop score.

Intravaginal Foreign Bodies Placed in the Vagina to Treat Uterine Prolapse Retained for 35 Years

Vaginal foreign bodies can cause long-term, foulsmelling vaginal discharge and bleeding, and are usually seen in female children while investigating vaginitis and urinary tract infections [1]. Foreign bodies are more frequently seen in children than in adults [2]. Reasons for the insertion of foreign bodies include treatment purposes, contraception, induced abortion, and sexual stimulation. Postmenopausal women rarely present with vaginal foreign bodies, even though foreign bodies may have been placed in the vagina for various reasons and subsequently forgotten. Various gynecologic techniques, including ultrasound and magnetic resonance imaging, can be used to detect foreign objects. Here, we report a case of insertion of a foreign body after menopause for contraception and to treat uterine prolapse. An 82-year-old woman with a history of seven normal vaginal deliveries who had undergone menopause 35 years earlier was admitted to our clinic, complaining of a foul-smelling vaginal discharge and bleeding of about 3 months’ duration. A gynecologic examination revealed a foul-smelling greenish discharge, but the cervix could not be visualized. A mass was observed where the cervix was expected, at a depth of about 5–6 cm within the vagina. The results of laboratory tests included a white blood cell count of 14,500/μL (normal, 4,000–10,000/μL), hemoglobin 11.6 g/dL (normal, 12.1–17.2 g/dL), and C-reactive protein 35 mg/L (normal, 0–3 mg/L). Liver and renal function tests were normal. Prophylactic antibiotic treatment was started because of signs of infection in the clinical and laboratory findings. Abdominal ultrasonography and computerized tomography revealed two masses of about 6 × 7 cm and 5 × 7 cm behind the urinary bladder. The uterus was atrophic, and no adnexal pathology was seen. Surgery was planned. A vaginal valve was placed in the vagina under spinal anesthesia and using the lithotomy position. A greenish mass was seen about 6 cm within the vagina (Figure A). The mass was removed using forceps and was found to be a 6 × 8 cm foul-smelling plastic ball with a spongy texture (Figure B). Many erosions and adhesions were seen in the vaginal wall because of the effects of the foreign body. A second mass was seen deeper than the first one (Figure C). This second mass was extracted using forceps and found to be another plastic ball of about 6 × 7 cm, with an empty centre. The two plastic balls are shown in Figure D. The cervix was atrophic and adherent to the vaginal wall. Erosion of the vaginal walls by the foreign bodies was thought to be the reason for the patient’s complaint. Surgery was completed. The balls were shown to the patient who stated that she had inserted them 35 years earlier for contraception and because of uterine prolapse. The patient was discharged without problem on the third postoperative day. She was followed up for 6 months after the operation. No uterine prolapse was detected because of the dense adhesions between the cervix and the vaginal wall. We searched PubMed and MEDLINE for case reports of vaginal foreign bodies. We found 20 case reports of vaginal foreign bodies, which are summarized in the Table. Eight of the patients were postmenopausal, as in our case. Fernando et al [3] reported two cases of neglected vaginal pessaries left in situ for prolonged periods; the first case had used a ring pessary for pelvic organ prolapse for 12 years, but had not had it replaced for the last 4 years, while the second case had a vaginal pessary inserted 32 years ago for pelvic organ prolapse. The authors concluded that the fibrosis caused by the retained pessaries could cure the prolapse. In our case, no uterine prolapse occurred after removal of the foreign bodies because of the dense adhesions between the cervix and the vaginal wall. INTRAVAGINAL FOREIGN BODIES PLACED IN THE VAGINA TO TREAT UTERINE PROLAPSE RETAINED FOR 35 YEARS